When is it OK to provide general anesthesia for a child receiving medical or dental care?
That is a question I’ve been asked often as a pediatrician, especially when a particular procedure is time-consuming or involves invasive treatment. General anesthesia may be an appropriate option when benefits outweigh risks, when its effectiveness may improve outcomes and when less invasive options have proven unsuccessful. Each child has to be evaluated each time a procedure is planned or considered.
The American Academy of Pediatric Dentistry and the American Academy of Pediatrics have issued guidelines for the safe and effective selection and administration of general anesthesia to pediatric patients. These guidelines were developed because of the risks associated with anesthesia, especially in children with complex medical conditions. These guidelines clearly state that an evaluation of the patient’s comprehensive medical history is a critical consideration before proceeding with anesthesia.
Given the risks, general anesthesia should be the last resort – not the first – when attempting treatment and when other options are applicable.
This is a view I’ve developed from my 15 years of pediatric practice and have carried into my role as chief medical officer for Health Plan of San Joaquin. Recently, I was alarmed to see that our plan receives two to 10 times as many authorization requests for general anesthesia for pediatric dental patients as other similarly sized health plans in California get. Even taking into consideration an increase in enrollment because of the Affordable Care Act, this is a significant deviation.
You might have read about this issue recently, as HPSJ has been the subject of several stories in The Bee concerning area dental surgery centers’ submissions of general anesthesia authorization requests for children.
HPSJ and its team of consulting community dentists and pediatricians require a thorough record of a child’s medical history, health concerns and developmental challenges to be provided before they will approve the use of general anesthesia. We have provided our dental surgery center partners with guidelines for authorization, yet continue to receive requests with little or no documentation. This is concerning, since HPSJ assumes the dental clinics must need the same information to judge whether a request for general anesthesia is medically necessary.
To be clear, HPSJ is authorizing general anesthesia procedures for children in cases where a medical need is documented. But the vast majority of the requests submitted to date fail to substantiate the medical need, and as a result the dental surgery centers are receiving fewer approvals for use of general anesthesia.
We are hopeful that through continued dialogue we can reach an agreement with dental providers that ensures children are receiving appropriate levels of care at the right time, and, importantly, for the right reasons.
Dr. Dhanvanthari is a member of the American Academy of Pediatrics and chief medical officer for Health Plan San Joaquin.